Category: Knowledge Base

What is COVID-19?

COVID-19 is short for coronavirus disease 2019. It is an infectious respiratory disease caused by the virus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), in the following referred to as coronavirus. 

COVID-19 was first identified in December 2019 in Wuhan, China, and in March 2020, the World Health Organization (WHO) declared the outbreak of COVID-19 a pandemic. As of 9 July 2020, more than 12 million cases have been reported all over the world, resulting in more than 500,000 deaths.

What are the symptoms of COVID-19?

Typical symptoms of COVID-19 include fever, cough, and tiredness, which may appear 2-14 days after exposure to coronavirus. However, the severity of symptoms varies considerably, and whereas some people do not experience any symptoms, others develop severe disease. Elderly people and people with chronic diseases are at higher risk of getting seriously ill if infected with coronavirus.

Is coronavirus transmitted via sexual activity?

Coronavirus is spread by respiratory droplets which are released when an infected person coughs, sneezes or talks. If you are within 2 metres of an infected person, you risk inhaling some of these droplets and be infected. 

Thus, being close to another person, whether this involves hugging, kissing, or having sex, involves a risk of being infected, if the person you are close to is infected with coronavirus. 

Coronavirus can also be present in faeces. Therefore, sex involving exposure to faeces also implies a risk of infection. 

Coronavirus has been found in semen samples from men with COVID-19 and in men recovering from the disease. However, there is no evidence that COVID-19 can be transmitted through semen or vaginal fluids. Likewise, COVID-19 has not been shown to be sexually transmitted.

Can I have sex with my partner?

If you and your partner are healthy and asymptomatic, practice social distancing and have had no known exposure to anyone with COVID-19, it is most likely safe for you to touch, hug, kiss, share bed and have sex.

If your partner is infected with COVID-19, you should avoid all close contact at least 7 days after the symptoms started. Your partner should self-quarantine and limit the use of common spaces. Clean common spaces regularly and wash all beddings.  

If you are infected with COVID-19, you should self-quarantine and avoid all close contact with your partner for at least 7 days after the symptoms started. Also, limit the use of common spaces, and clean these regularly. Wash all beddings.

Tips for reducing the risk of being infected with coronavirus while having sex

• Minimize the number of sex partners
• Do not have sex with a person who has symptoms of COVID-19
• Use a condom
• Do not kiss
• Avoid getting in direct contact with semen, urine, or faeces
• Wear a mask while having sex
• Wash hands and have a shower before and after having sex

What does science say about COVID-19 and sex life

Risk of transmission within the same household

Studies have reported that among people living together, only one out of six will get COVID-19 if another person in the same household has the disease. 

COVID-19 associated confinements and sex life satisfaction

A survey conducted among Chinese heterosexual men and women has analysed the implications of the COVID-19 pandemic and associated confinement and other precautions in terms of sex life. The results were as follows:

• One in four had a lower sexual desire
• One in three experienced a reduced sexual activity 
• 44% had a lower number of sex partners 
• About every third experienced a reduced overall sexual satisfaction.

COVID-19 pandemic and sexual health among men who have sex with men

In a survey on the sexual health of men who have sex with men, about half of the participants declared to have fewer sex partners due to the COVID-19 pandemic. Most of the participants had no change in condom access or condom use, while some reported difficulties in accessing HIV testing, prevention, and treatment services.

What are genetic causes of male infertility?

Male infertility can in some cases be due to detrimental alterations in the man’s genetic material – his DNA. In such cases, the infertility has a genetic cause.

How common are genetic causes of male infertility?

Genetic causes can be identified in one in every four to five men with severe infertility, meaning men who have no sperm cells in the ejaculate. In cases of reduced semen quality, genetic causes are rarely found.

Which are the most common genetic causes of male infertility?

The three most common genetic causes of male infertility are Klinefelter syndrome, microdeletions of the Y chromosome, and mutation in the CTFR gene. These causes give rise to rather different situations, which are described separately below.

How are genetic causes of male fertility diagnosed?

If analysis of a semen sample shows that a man has no sperm cells or very few sperm cells in the ejaculate, the doctor will have a blood sample analysed for genetic or chromosomal alterations.

Can genetic causes of male infertility be treated?

Genetic causes of male infertility cannot be treated. However, some men who are infertile because of genetic or chromosomal alterations can still have children by use of different assisted reproduction techniques. Details are provided below for the most common genetic causes of male infertility. 

Klinefelter syndrome

Klinefelter syndrome is the most common genetic cause of non-obstructive azoospermia. Non-obstructive azoospermia is the situation where no sperm is found in the ejaculate, and where this is not due to an obstruction of the ways leading the sperm from the testes to the tip of the urethra.  

Klinefelter is a chromosomal disorder. Rather than having 46 chromosomes, including the two sex chromosomes X and Y (46,XY), boys and men with Klinefelter syndrome have an additional X chromosome (47,XXY). 

Whereas most men with Klinefelter syndrome do not have any sperm in the ejaculate, mature and viable sperm can be found within the testes in about 40% of men with Klinefelter syndrome. 

If a man with Klinefelter syndrome wants to genetically father a child, a procedure called testicular sperm extraction (TESE) can be used to take out sperm cells directly from the testes. Via another procedure called intracytoplasmic sperm injection (ICSI), a single sperm cell can be injected directly into an egg. The fertilized egg is transformed into a proembryo and then transferred to the female partner’s uterus.  

Boys and men with Klinefelter syndrome also have a variety of other symptoms. Read more about Klinefelter syndrome here [link to text about Klinefelter syndrome]

Deletions of the Y chromosome

Sex chromosomes are called X and Y chromosomes. Whereas women have two X chromosomes, men have one X and one Y chromosome. The Y chromosome contains several genes critical for sperm production. Most of these genes are in areas of the Y chromosome called the AZF (azoospermia factor) regions. The AZF regions are constituted by the AZFa region, the AZFb region and the AZFc region.

Lack of one or more AZF regions, called AZF deletions, is a relatively common genetic cause of infertility in men with no or only few sperm cells in the ejaculate. 

If a man lacks the entire AZFa region or the entire AZFb region, he is unlikely to produce any sperm cells. This is also the case, if all three AZF regions are deleted.

The most frequent type of AZF deletion is, however, a lack of the AZFc region. Men lacking the AZFc region may still produce sperm cells. This is also the case in men who has a partial deletion in one of the AZF regions.

Men who have a specific partial deletion in the AZFc region, called gr/gr deletion, might have a reduced number of sperm cells in the ejaculate. However, other men with the same deletion can have normal sperm production.  

Men who are infertile because of an AZF deletion might still be able to genetically father a child, if there is some degree of sperm production in his testes. Via a technique called testicular sperm extraction (TESE), viable sperm cells can be extracted directly from the testes and used for in vitro fertilization. 

If a man with a Y chromosome deletion genetically fathers a son, he will inherit the Y chromosome deletion.

Mutation in the CFTR gene 

The most frequent genetic form of obstructive azoospermia is caused by mutations in the CFTR gene. 

Obstructive azoospermia is the situation where the transport of the sperm cells away from the testes, through the epididymis and via the vas deferens and ejaculatory ducts and the urethra is blocked, resulting in no sperm cells in the ejaculate.

Mutations in the CFTR gene cause congenital bilateral absence of the vas deferens (CBAVD). In addition, the epididymis is malformed and the seminal vesicles, which are involved in the production of seminal fluid, are absent. Consequently, the sperm cannot be transported away from the testes. 

CFTR is short for cystic fibrosis transmembrane conductance regulator, and CBAVD is referred to as the genital form of cystic fibrosis. Indeed, almost all men with cystic fibrosis also have CBAVD. However, some mutations in the CFTR gene can lead to CBAVD as the only abnormality, with no other signs of cystic fibrosis.

Since sperm cells are produced in the testes, a man with obstructive azoospermia can become the genetic father of a child, if procedures are used to extract the sperm cells directly from the testes or the epididymis. 

A man with mutations in the CFTR gene has the risk of getting a child that carries the CFTR gene mutations. Therefore, he and his partner should be offered genetic counselling. 

Por. Andrea M. Isidori talks about the importance of testicular self-examination and testicular ultrasound for andrological health.

What is gynaecomastia?

Gynaecomastia is the enlargement of breast tissue in men. 

It is important to distinguish between gynaecomastia and lipomastia, which may appear somewhat similar. Whereas gynaecomastia is enlarged breasts due to growth of the glandular tissue, lipomastia is enlarged breasts due to accumulation of fat. 

How common is gynaecomastia?

Gynaecomastia is a very common condition, especially in adolescents and in men above 50 years of age.

What are the symptoms of gynaecomastia?

Physically, gynaecomastia is usually a benign and painless condition. In a minority, pain and breast discomfort can occur. 

From a psychological point of view, having gynaecomastia can be extremely problematic. Especially in adolescents, it can give rise to shameful feelings and a lack of self-esteem, which again can lead to psychosocial and sexual problems.

For most adolescents, gynaecomastia is transient and disappears spontaneously after puberty.

What are the causes of gynaecomastia?

Gynaecomastia can result from an imbalanced ratio between androgens and oestrogens. A hormonal imbalance can for example be caused by an increased level of the oestrogen oestradiol or a decreased level or decreased effect of the androgen testosterone. A temporary imbalance in the oestrogen-to-androgen ratio is likely responsible for many cases of transient gynaecomastia seen during puberty.

In many cases, men develop idiopathic gynaecomastia. This means that no definite cause can be identified despite thorough medical assessment. 

In some cases, gynaecomastia is caused by hyperprolactinemia (elevated levels of the hormone prolactin in the bloodstream) or by thyroid disorders.

In a minority of cases, gynaecomastia is caused by an oestrogen-producing or hCG-producing tumour.

Drug-induced gynaecomastia is a common finding and often derives from the abuse of anabolic steroid, anti-androgens, and exogenous oestrogens. Other drugs, including some commonly used gastrointestinal and antihypertensive agents, may also give rise to gynaecomastia. In most cases, symptoms subside following drug discontinuation.

Who should I consult?

If you believe you have gynaecomastia, it is recommended to ask for a consultation with a specialist, e.g. a clinical endocrinologist, who can ensure that you are examined properly and get the correct diagnosis and treatment.

In cases of mental symptoms related to the gynaecomastia, psychological support can be recommended.

How is gynaecomastia diagnosed?

You will have a thorough clinical examination and be asked about your medical and drug history. A physical exam, including palpation of the breast tissue, is required to distinguish between true gynaecomastia and lipomastia

You will have a blood sample taken, which will be analysed for levels of relevant hormones, such as testosterone, oestradiol, and prolactin.

In some cases, scans and imaging techniques are used to determine the nature of the breast tissue.

How is gynaecomastia treated?

As gynaecomastia can be the consequence of a transient imbalance in hormone levels, treatment is rarely suggested in the first place. Rather, reassurance and follow-up are offered.

That said, treatments are available, and can be relevant to use to alleviate some of the psychological symptoms. 

Medical treatment in the form of selective oestrogen receptor modulators (e.g. tamoxifene) can be beneficial for some patients and is a relatively non-toxic therapy. 

For some men, surgical removal of the excessive breast tissue is an option, which can provide immediate relief from the physical and psychological discomfort.

What is male hypogonadotropic hypogonadism?

Male hypogonadism is defined as an impaired function of the testes. In male hypogonadotropic hypogonadism, the impaired testicular function is caused by insufficient hormonal stimuli from the pituitary or the hypothalamus, which are structures located in the brain.

How common is hypogonadotropic hypogonadism?

Hypogonadotropic hypogonadism can be congenital or acquired. Congenital hypogonadotropic hypogonadism is a rare condition, whereas the acquired form is relatively common.

What are the symptoms of hypogonadotropic hypogonadism?

The primary functions of the testes are to produce testosterone and sperm cells. Men with a poor testicular function due to hypogonadotropic hypogonadism therefore have symptoms of androgen insufficiency and impaired spermatogenesis.

Symptoms of androgen insufficiency include lack of energy, weight gain, sexual dysfunctions, and a diminished libido.

An impaired spermatogenesis means that the production of sperm cells is affected. This can cause subfertility or even infertility.

Signs of hypogonadotropic hypogonadism depend on time of onset. In adolescents, it can be difficult to distinguish the symptoms of hypogonadotropic hypogonadism from the symptoms of delayed puberty.

What are the causes of male hypogonadotropic hypogonadism?

Congenital hypogonadotropic hypogonadism normally has a genetic cause. Kallmann syndrome, caused by mutations in the KAL1 gene, is the best-defined cause of congenital hypogonadotropic hypogonadism. 

Acquired hypogonadotropic hypogonadism can have multiple causes:

• Brain trauma
• Brain surgery or irradiation
• Some medications
• Abuse of anabolic steroids
• Abuse of alcohol
• Systemic diseases

While medications often lead to transient hypogonadotropic hypogonadism, it can take a long time to recover from abuse of anabolic steroids.  

Who should I consult?

Diagnosis and treatment of hypogonadotropic hypogonadism should be carried out by a clinician specialized in these conditions. This will ensure the best outcome for you, both in terms of proper androgen supplementation and restoration of your fertility. 

How is hypogonadotropic hypogonadism diagnosed?

You will give a blood sample, which is analysed for levels of testosterone, LH and FSH. The hormones LH and FSH, collectively known as gonadotropins, are produced in the pituitary and stimulate the testes to produce testosterone and sperm cells under normal conditions.

In case of hypogonadotropic hypogonadism, testosterone, LH and FSH levels are low. 

In some cases, you will also have a GnRH stimulation test, which enables the measurement of GnRH levels. The hormone GnRH is produced in the hypothalamus and stimulates the pituitary to produce the gonadotropins LH and FSH. Measurement of GnRH helps the clinician to determine, whether the reason for insufficient gonadotropins is due to pituitary alterations or to lack of GnRH stimulation from the hypothalamus.  

How is male hypogonadotropic hypogonadism treated?

Treatment with hormones acting like LH and FSH can replace the lacking pituitary hormones. In most cases, such gonadotropin replacement therapy restores sperm production and testosterone levels, and thereby alleviates or even removes the symptoms of hypogonadotropic hypogonadism. 

Gonadotropin replacement therapy is, however, troublesome, requiring several injections a week. Use of portable infusion pumps administering pulses of GnRH is another option, although the price is high, and its use is restricted to highly specialized centres. 

If you are an adult man, who do not have a current desire for fathering a child, treatment will focus on testosterone replacement therapy only. Testosterone therapy is available in several forms, including gels, skin patches, pills, and injections. In prepubertal boys with hypogonadotropic hypogonadism, gonadotropin replacement therapy is required to ensure a normal development of secondary sex characteristics during pubertal years. Such a treatment will be closely monitored by specialized clinicians. After puberty, gonadotropin replacement therapy can be replaced by the more convenient testosterone replacement therapy.  

What is varicocele?

Varicocele is an abnormal enlargement of the network of small veins found in the spermatic cord of the testis. 

Varicocele is a benign condition that does not imply any serious health issue or is related to the onset of cancer.

In about nine out of ten cases, the varicocele is located in the left testis. In few cases, varicocele is found in both testes, whereas varicocele in the right testis is a rare phenomenon. 

How common is varicocele?

Whereas varicocele is found in about 15% of all men, the incidence is somewhat higher in infertile men. One in four men with a reduced sperm quality have varicocele.

Often, the condition develops during puberty.

What are the symptoms of varicocele?

Most men with varicocele have no symptoms. Often, the varicocele is found because the man sees a doctor due to fertility problems. 

In some men with varicocele, the dilated veins are palpable from the outside. 

Some men have testicular pain because of varicocele. 

What are the causes of varicocele?

The dilatation of the small veins in the spermatic cord is caused by reduced blood drainage away from the testicular vein network and into the venous system. Consequently, venous blood pile up in the testis, which results in increased hydrostatic pressure and increased testicular temperature. This can impair the function of the cells in the testicle responsible for supporting the production of sperm cells. As a result, the man’s fertility can be affected.

How is varicocele diagnosed?

You might be able to identify a varicocele by self-exam of the scrotum, as they can look and feel like a ‘bag of worms.’ Go see a doctor, if you think you have a varicocele.

The doctor will give you a clinical assessment including a physical examination of the scrotum. 

Sometimes, the doctor will make an ultrasound scan of your testes, to support the diagnosis based on the physical examination. 

How is varicocele treated?

Most men with varicocele are not treated. Only in cases where the man has testicular pain or impaired semen quality and fertility problems, treatment is offered. Pubertal boys, whose left testis grows more slowly due to a varicocele will also be offered treatment. 

Varicocele can be treated surgically by microscopic varicocelectomy or by a non-surgical procedure called percutaneous embolization. Mild testicular pain can be released by taking pain-killers such as acetaminophen and ibuprofen.

The recommended treatment is microsurgical varicocelectomy. Here, the surgeon makes a small incision above the scrotum through which all small veins are ligated. The surgeon uses a microscope while ligating the veins and is careful not to harm the testicular arteries and lymphatic drainage. 

The alternative treatment form, percutaneous embolization, is done by an interventional radiologist and uses injected contrast, x-ray guidance and coils or balloons to block the blood flow to the varicocele. 

For both treatment forms, healing after surgery is relatively fast and pain is mild. Few men experience complications after surgery or have recurrence of the varicocele. Semen quality will improve in some, but not in all, men who have been treated for varicocele due to fertility problems.

What is premature ejaculation?

Premature ejaculation is a condition in which ejaculation occurs sooner than desired.

In clinical terms, premature ejaculation is ejaculation occurring during partnered sexual activity within 1 minute after vaginal penetration and before the individual wishes it, in almost all or all sexual activity, persisting for at least 6 months and causing significant distress to the individual.

Cases where the dysfunction is better explained by nonsexual mental disorder, a medical condition, drug side effects, severe relationship distress or other significant stressors are not defined as premature ejaculation.

How common is premature ejaculation?

Between 8 and 30% of adult men have premature ejaculation, making it the most common male sexual dysfunction. Given the culture-dependent and couple-linked nature of the problem, and a tendency of underreporting, the exact prevalence is difficult to determine.

What are the causes of premature ejaculation?

Premature ejaculation can have several causes and might be caused by a combination of different things.

Hormonal alterations, for example the thyroid disorder hyperthyroidism, can decrease the time needed for ejaculation.

Some medications can have premature ejaculation as a side effect.

Increased penile sensitivity is considered a contributing factor in premature ejaculation.

Psychological issues, such as lack of self-confidence, anxiety, and relationship problems, can cause premature ejaculation.

Erectile dysfunction and premature ejaculation are often intertwined. Thus, anxiety from impaired erectile function can cause premature ejaculation, as can the need for suppressing sexual stimulation to delay ejaculation.

How is premature ejaculation diagnosed?

The doctor will ask about your medical history and whether you take any medicine. This is because certain drugs and medications can give rise to premature ejaculation.

You will have a thorough physical examination. The physical exam is important to detect possible physical causes of premature ejaculation, such as deformation of the penis, tight foreskin, prostate inflammation, and infections in the genital tract.

You will have a blood samples taken, which will be analysed for levels of thyroid hormones, testosterone, prolactin, and other hormones. This is done to investigate, whether some underlying endocrine disease is the cause of your problem.

You will also have a psychological evaluation, as premature ejaculation often has a psycho-sexual cause.

Your doctor might encourage you to use a stopwatch to measure the time needed from the onset of sexual intercourse to ejaculation. It is a cumbersome, yet effective tool to assess the severity of premature ejaculation.

Diagnosing a physical reason for premature ejaculation does not automatically rule out psychological causes. It may be a combination of both.

How is premature ejaculation treated?

If an underlying cause of premature ejaculation is identified, this will be treated first. For example, if you lack testosterone, you will get testosterone replacement therapy, and if you have hyperthyroidism, you will receive thyrostatic drugs. Likewise, tailored treatments for erectile dysfunction and prostate inflammation will be provided. If symptoms of premature ejaculation persist despite treatment of the underlying conditions, you will have a treatment targeting premature ejaculation directly.

Local anaesthetics can help to decrease penile sensitivity and thereby delay ejaculation. These treatments, however, have potential side effects, including a temporarily decreased sexual pleasure and loss of sensitivity, which can also transfer to the partner.

Oral medications include a drug called dapoxetine, which in many countries is considered the first choice of treatment for premature ejaculation. Dapoxetine is an antidepressant drug that belongs to the family of SSRIs, which have delayed ejaculation as a common side effect. Dapoxetine only have limited antidepressant effects and is rapidly eliminated from the body, which make it quite valid as a treatment of premature ejaculation. SSRIs, including Dapoxetine, can, however, have side effects like loss of libido, nausea, and drowsiness.

Psychological counselling can help in coping with anxiety, anger, lack of self-confidence and stress, and as such is a useful treatment for premature ejaculation for some. Different strategies and techniques are available for psychological intervention, focusing on either the individual or the couple.

Often, a combination of psychotherapy and drug treatment give the best results.

Behavioural techniques, like pelvic floor exercises, the “stop-and-start” technique and the “squeeze” method, are often suggested as forms of self-administered treatment. However, the evidence for the effect of these techniques is debated.

What is male infertility?

Infertility is defined as the inability of a couple to achieve a spontaneous pregnancy within a year despite regular intercourse without contraception. Male infertility refers to situations where the lack of pregnancy in the female partner can be attributed to male factors.

How common is male infertility?

Male infertility is a common phenomenon. Currently, about one in every seven couples do not achieve pregnancy within one year and therefore seek medical treatment for infertility. In about half of these cases, a male factor is identified.

What are the symptoms of male infertility?

Most infertile men do not have any physical symptoms. Infertility can, however, be a substantial psychological burden, both for the couple and, in cases of male infertility, for the man himself.

What are the causes of male infertility?

Male fertility generally depends on the quality and quantity of the sperm cells, and the ability of these sperm cells to reach and enter the egg inside a woman. In infertile men, one or more of these factors are compromised.

Causes of male infertility are multiple and include:

• Undescended testes or a history of undescended testes
• Malignancies
• Infections in the urogenital tract, including sexually transmitted diseases
• Varicocele
• Hormone imbalance
• Hypogonadotropic hypogonadism
• Genetic abnormalities
• Immune factors or immune disorders
• Vasectomy or other obstructive factors of the seminal ducts or the prostate
• Erectile dysfunction
• Hypospadias
• Retrograde ejaculation
• Aging
• Idiopathic (unidentifiable reason)

Whereas some of these causes interfere with the quantity and quality of the sperm cells (e.g. undescended testes and some genetic abnormalities), other causes are related to the ability of the mature sperm cells to reach the female genital tract (e.g. vasectomy and retrograde ejaculation).

When should I consult a doctor?

If your partner is <35 years, and the two of you have had a sex life without the use of contraception and with regular intercourse during the fertility window of your partner for at least 12 months without her getting pregnant, you and your partner should see a doctor.

If your partner is >35 years, and the two of you have had a sex life without the use of contraception and with regular intercourse for at least 6 months without her getting pregnant, you and your partner should see a doctor. The shorter ‘waiting’ time in couples where the woman is above 35 years enables a sooner initiation of assisted fertility treatment, if needed, which is specifically relevant in these couples considering the age-related decline in female fertility.

If you are aware that you have a particular risk of being infertile or subfertile, it is a good idea to see a doctor and have your fertility potential evaluated.

How is male infertility diagnosed?

The clinician will ask about your medical history and you will have a physical examination.

You will have a blood sample taken and be asked to deliver a semen sample. Often, the clinician will like to have two semen samples analysed, since the semen parameters may vary.

The semen samples are analysed for total sperm count, sperm concentration, sperm motility and sperm morphology. The blood sample is analysed for relevant hormones, and, in some cases, certain genetic abnormalities.

In some cases, the doctor will make an ultrasound scan of your testes.

In quite many cases, a poor semen quality is documented, whereas no underlying cause can be identified.

Can male infertility be treated?

Whether or not male infertility can be treated depends on the cause of the problem.

About 15% of infertile men have a treatable condition. These include for example some cases of retrograde ejaculation, varicocele, and hypogonadotropic hypogonadism.

Many cases of male infertility are, however, not treatable. These include for example genetic causes, idiopathic infertility, and infertility due to undescended testes. Still, the use of assisted reproductive technologies (ART) can in many cases help a couple overcoming infertility and have a baby, even though it does not treat the infertility per se. There are different kinds of ART, and the approach chosen will depend on the kind and degree of infertility in the specific case, as well as on the female partner’s situation.

In some cases, neither treatment nor ART can overcome infertility.

What is erectile dysfunction?

Erectile dysfunction is defined as trouble getting and keeping an erection firm enough for sex.

Having problems getting an erection now and then is completely normal. However, if the inability is persistent and troublesome, it can be defined as erectile dysfunction.

How common is erectile dysfunction?

Erectile dysfunction is a very common sex problem and becomes increasingly common as men age. However, growing old does not always entail erectile dysfunction in men. Some men are sexually functional into their 80s.

What are the symptoms of erectile dysfunction?

Some men can get an erection but are unable to keep the erection long enough to have sex.

Some men can get an erection, but do not get the erection when he wants to have sex.

Some men cannot get an erection at all.

What are the causes of erectile dysfunction?

Erectile dysfunction can have many different causes. Since the body and the mind must collaborate for sexual function to work, problems both of physical and of psychological nature, or a combination of both, can give rise to erectile dysfunction.

Physical causes of erectile dysfunction include:

• Restricted blood flow to the penis. Erection is caused by blood trap in the penis. Underlying health issues like peripheral artery disease, atherosclerosis, heart disease, or diabetes can appear as erectile dysfunction because it limits the flow of blood to the penis. Sometimes erectile dysfunction is the first sign of such underlying disease.
• Inability to trap blood during an erection. This means that blood will flow to the penis and cause an erection. However, since the blood is not trapped in the penis, erection will fall again.
• Lack of nerve signals. Erection is dependent on nerve signalling from the brain and the spinal cord. If nerves are harmed due to disease, injury, or surgery in the pelvic region, this can manifest as erectile dysfunction.
• Some medicines can cause erectile dysfunction.
• Cancer treatment. Surgery and radiation in the pelvic region can affect the penis’ function. Examples are treatment of prostate, colorectal or bladder cancer.

 

Psychological causes of erectile dysfunction include:

• Anxiety
• Depression
• Conflicts in the relationship
• Stress, either at home or at work
• Stress from social, cultural, or religious conflicts
• Lack of self-confidence in terms of sexual performance

How is erectile dysfunction diagnosed?

The doctor will ask about your medical history, your general health, and the nature of your erectile dysfunction. He or she may also give you a physical exam and take a blood sample.

Details about your medical history and general health are important because factors like medicine, smoking and alcohol may all contribute to erectile dysfunction, as may a history of radiation therapy or surgery.

Information about your experience with sex and erectile dysfunction can help the doctor elucidate the origin of the problem, and whether the dysfunction is related to the desire for sex, or to erection function, ejaculation, and orgasm. Your doctor may also ask about your emotional health and your relationship with your partner, and whether you feel stressed.

The physical examination will include an exam of your penis and your testicles. Often, your blood pressure and pulse are measured, and in some cases a rectal exam is done to check your prostate.

The blood sample will be analysed for relevant hormones and, if relevant, factors related to cardiovascular health.

More advanced erectile function tests, like ultrasonography, scans, penile injection with a vascular stimulant or test of sleep erection overnight might be done in some cases.

How is erectile dysfunction treated?

Relevant treatment will depend completely on the underlying cause or causes of the problem.

Lifestyle changes

If your erectile dysfunction is caused by a lifestyle-related general health problem, including impaired cardiovascular health, your doctor can advise you to change your lifestyle. Changes can include:

• Better eating habits, like more plant-based food and less high-fat and processed food
• Maintain a healthy weight
• Quit smoking
• Increase exercise
• Limit the use of drugs and alcohol
• Get more sleep, preferably 7-8 hours per night

Psychological support

If your erectile dysfunction is caused by emotional problems, you can be offered psychological support, for example from a sexual health counsellor or a general health counsellor. 

Medical treatment

While lifestyle changes and/or psychological support are often first choices, medical treatments are also available for erectile dysfunction. These include:

• PDE type-5 inhibitors which function by increasing penile blood flow. PDE type-5 inhibitors are pills that should be taken by mouth an hour or two before having sex.
• Alprostadil, which causes vasodilation and thereby increased penile blood flow. Alprostadil can be given by self-injection in the penis, via a pellet placed in the urethra or via a creme applied to the tip of the penis.
• In cases where low testosterone levels are detected, testosterone replacement therapy may improve the libido. In combination with PDE type-5 inhibitors, this can help some men getting an erection.

Mechanical device

Mechanical assistance can be provided in the form of a vacuum erection device. This is a plastic tube that slips over the penis, making a seal with the skin of the body. Pressure from a pump at the other end of the tube makes a low-pressure vacuum which results in an erection. An elastic ring is then slipped onto the base of the penis to trap the blood in the penis.

Penile implant
A penile implant, also called a penile prosthesis, is a surgical treatment. This may be a good solution for men, who have not had success with other treatments, or who have erectile dysfunction because the prostate has been removed by surgery due to prostate cancer. Penile implants can be semi-rigid or inflatable. Whereas they may help with erections, any cancer-treatment induced damage to sensation, orgasm or ejaculation will not be alleviated.